Pay no attention to the people behind the curtain

Monday, November 20, 2006

Health Care He Said-She Said: I Say, Simplify

Two Wisconsin Congresscritters wrote dueling op-eds in the Sunday Journal Sentinel, Privatizin' Paul Ryan and Slammin' Tammy Baldwin. They do a he said-she said on health care.

I wonder what would happen if you took the two essays, Rayn's and Baldwin's, stripped the authorship information from them, and presented them to the public, which one of the two positions the public would prefer. Because, as I read them, it comes down to this:

Baldwin: Health care is so expensive because it's such a complicated system.Ryan: Health care is so expensive because the system is not complicated enough.

The choice is pretty clear in my mind--why would we want to make the way we purchase and pay for health care more complex? Who, exactly, does that appeal to? Cui bono--who benefits from a more complicated system? Certainly not health care consumers. Probably not doctors and other providers, either.

Oh, but Jay, you're thinking, surely you're being reductionist and Ryan's and Baldwin's ideas are more nuanced than that. Well, I don't think what I wrote is an unfair rendering of their arguments. See for yourself; here they are in their own words:

Baldwin:We don't have the time or the space to go into details on the overuse of services, the duplication of services, fraud and other factors that all contribute to the unnecessarily exorbitant and inherently unfair cost of health care in this country.

It's been seven decades since President Truman first called for health care for all in this country, but we still have an inadequate health care system. [. . .] Under a single-payer system, all Americans would be covered for all medically necessary services. Patients would regain free choice of doctor and hospital, and doctors would regain autonomy over patient care.

A single-payer system would be financed by eliminating private insurers and recapturing their administrative waste. Modest new taxes would replace premiums and out-of-pocket payments currently paid by individuals and business. Costs would be controlled through negotiated fees, global budgeting, and bulk purchasing. [. . .] The costs of health care will never be controlled until we, as a nation, make a commitment to guarantee health care for all and then make that happen most efficiently and economically.

***

Ryan: [T]he heart of what is actually driving runaway medical expenses [is] the lack of a working free market in health care that puts power in patients' hands. [. . . W]e need to make sure patients can access reliable, up-to-date information on what hospitals and doctors actually charge for medical procedures. [. . ] Making sure the public has access to this kind of data, as well as information about the quality of care patients receive, is essential to fostering competition and lowering costs.

While consumers need accurate information to make sound judgments and select the best health care provider to meet their needs, they also need tools that give them more control over their health care purchases and make coverage more affordable. [. . .]

Health savings accounts are a relatively new option for health care coverage that enables individuals to set aside tax-free savings for future medical expenses. I co-wrote the law that took effect in January 2004 to permit HSAs, and they have become an increasingly popular way to obtain coverage and manage health costs. [. . .] HSA holders or their employers buy a high-deductible insurance plan to take care of large hospital bills, and they use money from their HSA to pay for check-ups and other routine medical expenses. [. . .] They also give patients an incentive to pay attention to what they spend and seek the best deal, in terms of price and quality, which will help bring down the cost of health care.

Transparent pricing doesn't really help much when your insurance plan doesn't cover the cheaper hospital or the cheaper doctor, does it? The last round of conservative-driven reform in the health care industry centered around HMOs and other managed-care plans, which made explicit and rigid the rules limiting where patients could seek treatment. Even under my teachers-union insurance, which is most assuredly not an HMO, I pay quite a bit extra for out-of-network services (some of which, like pathologists, I may not have a choice about). What good does it do me to know I could save my insurance company $10,000 on an operation if I went to a hospital that would cost me thousands out-of-pocket? Am I really going to make that choice?

And I've never understood the conservative fetish for HSAs--they apparently think you have too much insurance. And if only you had less, you'd be healthier, or at least you'd go to the doctor less often. That is just about the worst public health policy I could imagine. I mean, I may have the luxury of deciding that it's not worth fixing the suspension on my 1997 Saturn (it really isn't); I don't have the luxury--none of us should--of deciding that it's not worth seeing the doctor for this or that ailment just in case something worse comes along. And, indeed, it's prevention and preventive care--something HSAs discourage--that is the strongest reform we could make to our health care system. Even if only a small percentage of catastrophic cases could be prevented, the savings to the system would more than make up for the increased cost for wide-spread preventive care.

To be fair, Paul Ryan does support some reasonable reforms; indeed, I've endorsed the idea of pricing transparency as part of a wider set of reforms, and he supports a tax credit on premiums. But he neglects to mention that some of the reforms he supports have downsides. For example, the innocuous-sounding bill to allow small businesses to form "trade associations" and buy health care from cheaper "out-of-state" providers was the infamous "Enzi Bill," a bill that would have allowed employers in one state to avoid that state's laws, laws which might require covering certain conditions or treatments. That bill was opposed by everyone from the AARP to 39 state Attorneys General.

And, to keep being fair, Tammy Baldwin stops short of actually proposing a single-payer system, with the cop-out that "no single health care reform proposal, not a single-payer plan nor the more conservative, employer-based programs, have any chance of gaining the majority of votes necessary for passage at this time." Which is too bad, since now that there is some momentum in Congress for change, Baldwin should take the gloves off and see what she can get done.

In the end, there is no way we can avoid the unpleasant facts: As the only major industrialized nation without some kind of single-payer system, the United States pays double--in terms of GDP and per-capita cost--what other nations do for health care, without double the results. In fact, experts peg the death toll due to underinsurance in this country at between 20,000 and 80,000 annually; how much greater is the drag on our economy from the many hundreds of thousands or millions more who don't die, but just lose days of work? The only solution, in the end, is one which guarantees everyone a certain level of care. HSAs won't do it. A more transparent system of pricing won't do it. Even tax credits on the cost of a premium won't do it.

And while Ryan repeats the standard dire warnings about Canada, I will repeat my plea that we could be more like France--a country you never hear conservatives warn about because single-payer works there, and works well.

Health care is not so expensive because it isn't yet complicted enough, and Ryan's plea for more piecemeal and patchwork answers is the wrong way to go. Instead, let's follow the advice Baldwin offers: Simplify.